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Quality of the Antibiotics--Amoxicillin and Co-Trimoxazole from Ghana,

Nigeria, and the United Kingdom

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DOI: 10.4269/ajtmh.14-0539 · Source: PubMed

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Am. J. Trop. Med. Hyg., 92(Suppl 6), 2015, pp. 87–94
doi:10.4269/ajtmh.14-0539
Copyright © 2015 by The American Society of Tropical Medicine and Hygiene

Quality of the Antibiotics—Amoxicillin and Co-Trimoxazole

from Ghana, Nigeria, and the United Kingdom
Ifeyinwa Fadeyi, Mirza Lalani, Naiela Mailk, Albert Van Wyk, and Harparkash Kaur*
London School of Hygiene & Tropical Medicine, London, United Kingdom

Abstract. Little is known about the quality of antibiotics despite being in high demand globally. Thirty five samples
(27 brands) of the antibiotics amoxicillin (N = 20; 16 brands) and co-trimoxazole (N = 15; 11 brands), manufactured in six
countries (China, Ghana, India, Ireland, Nigeria, and United Kingdom), were purchased in Ghana, Nigeria, and the
United Kingdom. Their quality was assessed using German Pharma Health Fund (GPHF) MiniLabÒ as the screening
tool—two capsules of amoxicillin (10%) and two tablets of co-trimoxazole (20%) failed the thin-layer chromatography
(TLC) test. Definitive drug quality was measured using high-performance liquid chromatography–photodiode array
detection (HPLC-PDA) for content of the stated active pharmaceutical ingredients (APIs) and bioavailability was
determined with in vitro dissolution testing. All the samples of amoxicillin complied with U.S. Pharmacopeia (USP)
tolerance limits, but 60% tablets of co-trimoxazole (purchased in Ghana and Nigeria) did not. There was disparity in the
results obtained for co-trimoxazole and amoxicillin samples using the MiniLabÒ TLC tests. This highlights the need to invest
in techniques such as HPLC-PDA and dissolution testing alongside the screening tests for assessing drug quality.

INTRODUCTION
Antibiotics such as co-trimoxazole (sulfamethoxazole/
trimethoprim—a dihydrofolate reductase inhibitor and a
sulphonamide) and amoxicillin (a b-lactam) are used globally
in the public health sector for treatment of bacterial infections.
Antibiotics in general are crucial for use as chemotherapeutic
agents in treating bacterial infections and microbe-borne dis-
eases making them vital for the prevention of mortality in
pneumonia, diarrheal diseases, human immunodeficiency virus
(HIV), tuberculosis, and malaria.1–3 Co-trimoxazole is com-
monly used as prophylaxis against secondary bacterial infec-
tions among HIV-1-infected tuberculosis patients for whom it
has shown a marked reduction in morbidity and mortality
rates.4 Amoxicillin is a broad-spectrum antibiotic used for the
treatment of several bacterial infections.5
There is widespread concern about the quality of antima-
larial drugs, with up to 35% poor quality antimalarials reported
to be in malaria-endemic countries.6,7 However, little is known
about the quality of antibiotics, despite being in high demand
globally. Manufacturers of “counterfeit”8 drugs target econom-
ically profitable medicines, as well as those that have high
volume sales. Over a period of 5 years, 2006–2010, 1.34 billion
antibiotic prescriptions were dispensed in the United States.9
Data are limited from the developing world where first-line
antibiotics can be easily obtained without prescription from
pharmacies, grocery shops, and even mobile drug peddlers.10,11
The use of poor quality drugs can lead to poor treatment
outcomes, waste of financial resources by prolonging illnesses,
increase the potential of recrudescence, and propagate the
development of drug resistance.12 Instances such as these
reduce consumer confidence in health systems, health profes-
sionals, and the pharmaceutical industry.
A limited number of scientific investigations have assessed
the prevalence of poor quality antibiotics.13,14 A study carried
out of antibiotics purchased in the middle east and north Africa
found that there was a substantial amount of locally produced
amoxicillin that did not comply with drug monographs in the
U.S. Pharmacopeia (USP).15 Indeed data available on the qual-
ity of anti-infective drugs mainly focus on antimalarial drugs.16
The assessment of the quality of drugs in developing coun-
tries that do not have a medicines quality control laboratory
(MQCL) is often a two-stage process. The first involves the
screening of drugs, which can be carried out in the country
where the drugs have been purchased provided they have a
portable laboratory, in particular the German Pharma Health
Fund (GPHF) MiniLabÒ.17 The MiniLabÒ contains four basic
tests: visual inspection, tablet/capsule disintegration, colori-
metric tests,† and thin-layer chromatography (TLC). The
MiniLabÒ is regarded as a simple and inexpensive testing kit
requiring minimal training and no electricity to operate. The
U.S. Agency for International Development (USAID) through
its implementing partner USP identifies the MiniLabÒ as a key
aspect of its Promoting the Quality of Medicines (PQM) pro-
gram in several developing countries.18
The second stage is to detect the ingredients in each drug
sample at a MQCL using the technique of high-performance
liquid chromatography (HPLC) to then quantify the amount
of active pharmaceutical ingredients (APIs). HPLC is regarded
as the gold standard for drug quality analysis as it offers accu-
racy, specificity, and precision in quantifying the amount of
stated API detected or its absence. In vitro, dissolution testing
offers valuable prediction of the in vivo bioavailability and
bioequivalence of tablets and capsules. Dissolution tests mea-
sure the amount of drug released into the dissolution media
with time following detailed protocols (official monographs)
set out for most drugs in pharmacopeias (e.g., European, British,
USP, World Health Organization [WHO] International). The
protocols outline the details of the test conditions (dissolution
buffer/solvents, stirring speed, tolerance levels of the API, and
temperature for the assay). Even if the quantity of API in a
medicine is within pharmacopeia’s tolerance limits for content,
the amounts released (bioavailability) may be lower giving
poor dissolution characteristics. The dissolution tests require
sophisticated apparatus as well as the analytical equipment

*Address correspondence to Harparkash Kaur, London School of

Hygiene & Tropical Medicine, Keppel Street, London WCIe 7HT, †According to the manufacturer of the MiniLabÒ the colorimetric
United Kingdom. E-mail: harparkash.kaur@lshtm.ac.uk test is no longer recommended as part of the screening process.

87
88 FADEYI AND OTHERS

Figure 1. Map of Nigeria.20

such as HPLC, and most crucially the latter analysis requires

the reference standards of the compounds being tested for
calibrating the equipment, which can be both expensive and
difficult to obtain.19
This study was undertaken to determine the quality of anti-
biotics among varying brands of amoxicillin and co-trimoxazole
purchased in Kintampo town (Ghana); Agbor town, Delta state,
and Lagos city (Nigeria); and Milton Keynes (United Kingdom).
Drug quality was assessed at our laboratory in London using the
GPHF MiniLabÒ as the screening tool, HPLC–photodiode
array detection (PDA) to measure content of formulations and
the in vitro dissolution testing adhering to USP monographs to
decide on the bioavailability of the antibiotic samples.

MATERIALS AND METHODS

Sampling the antibiotics. Samples of amoxicillin and

co-trimoxazole were purchased from a variety of drug outlets
including; pharmacies, licensed chemical stores, and drug
vendors in Ghana, Nigeria, and United Kingdom using a con-
venience sampling method with an overt approach. This sam-
pling method involves the purchaser buying the medicines
without specific guidance on which outlets to visit. All outlet
owners in each country were informed of the nature of the study
prior to purchasing the samples. The places in Nigeria where
samples were purchased are shown on the map in Figure 1.20
In Ghana, samples were purchased in Kintampo, a major town
in the central part of the country (Figure 2).21 Samples from
Milton Keynes (United Kingdom) were donated by a local
pharmacy. Samples of the same brand, but with different batch
numbers were classified as an individual sample. A total of
20 samples (16 brands) of amoxicillin and 15 samples of Figure 2. Map of Ghana.21
 QUALITY OF ANTIBIOTICS
co-trimoxazole (11 brands) were acquired by asking the outlet
for all the brands of available antibiotics that they stocked at
the time of sampling.
Ethics approval. The London School of Hygiene and Trop-
ical Medicine research ethics committee approval (Ref: 5804)
was secured for the purchase of the antibiotics.
Sample logging. The packaging and/or blister packs of all
the samples were logged in the data collection tool (Epi Info
version 3.5),22 which is a public domain statistical software for
epidemiology developed by Centers for Disease Control and
Prevention in Atlanta, GA, to capture information including
brand name, stated APIs, dose form, country of sample col-
lection, date of purchase, name of stated manufacturer, coun-
try of manufacture, batch number, date of manufacture,
expiry date, and number of capsules/tablets per packet (pack
size). Each sample was placed in an individual ziplock bag and
given a bar code. All samples were logged onto a database,
and tablets weighed and measured prior to laboratory analy-
sis. Drug quality analyses were conducted on a minimum of
two tablets or two capsules.
Drug quality analysis. All samples were assessed for their
quality in our laboratory in London using the GPHF MiniLabÒ
as the screening tool.17 The amount of stated API for the
content analysis and release over time for the in vitro disso-
lution testing was measured using HPLC-PDA, following
USP monographs.23
Visual inspection. All the packaging and blister packs of
formulations were digitally scanned to record any abnormal
spelling or unduly faded color of the packaging as a result of
being stored in direct sunlight and/or high humidity. Each
formulation (tablet or capsule) was also weighed and mea-
sured using electronic digital calipers.
Drug quality screening test (GPHF MiniLabÒ). All the
samples were tested using two of the tests in the MiniLabÒ
following the manual instruction for each drug.17
• Colorimetric test detects the presence of the stated API.
• TLC test identifies the APIs present in each sample.
HPLC-PDA conditions. Reference standards of amoxicil-
lin, sulfamethoxazole, and trimethoprim were purchased from
Sigma-Aldrich, Dorset, United Kingdom. All equipment and
solvents used were purchased from Thermofisher Scientific,
Hemel Hempstead, UK.
HPLC analyses were carried out using a Dionex Ultimate
3000 HPLC system. In brief, samples were separated on an
Acclaim 120, C18, 5-mm analytical column (4.6 150 mm) from
+
Fisher Scientific, Leicestershire, United Kingdom, with gradi-
ent elution from 100% solvent A (20 mM ammonium formate
[pH 2.7]) to 100% solvent B (acetonitrile) over 6 minutes at a
flow rate of 1.4 mL/min. The photo-diode array detector (UV-
PDA; DAD 3000) was set at 275 nm (better resolution of the
peak of amoxicillin is achieved at 230 nm). Figure 3 shows the
separation of the three compounds. Peak identity of amoxicil-
lin, sulfamethoxazole, and trimethoprim was confirmed by
measuring the retention time, spiking the sample with commer-
cially available standards and determination of absorbance spec-
tra using the UV-PDA. Calibration curves of each compound
were generated by Thermofisher Scientific Dionex Chromeleon
7.2 chromatography data system software (Thermofisher Scien-
tific, Hemel Hempstead, UK) using known amounts of the
relevant standard. The coefficient of determination for amoxi-
cillin was 99.39%, for trimethoprim 97.83%, and for sulfameth-
89
oxazole 99.60%. Results for the content analysis are expressed
as a percentage of the detected API in a given sample from
the stated dose on the packaging. For dissolution testing, the
amount of API released over time was monitored using our
in-house HPLC-PDA method for the analysis of the aliquot,
to determine compliance with USP tolerance limits.
Content analyses. Content of the formulations of amoxicil-
lin and co-trimoxazole was measured by dissolving each for-
mulation in solvent (0.1 M HCl for amoxicillin and methanol
for co-trimoxazole) to give a 1 mg/mL solution that was fur-
ther diluted to obtain a 0.5 mg/mL solution, and analyzed
using our in-house HPLC method outlined above.
The USP rules for content analysis stipulate that for each
tablet of amoxicillin 90–120% stated API should be mea-
sured, and for co-trimoxazole it should be 93–107%.
Dissolution analyses. The quality of the formulations of
amoxicillin and co-trimoxazole was determined using the
Pharma Test PT 017 dissolution apparatus (Pharma Test
GroupPharma, Hainburg, Germany) following the in vitro
dissolution testing protocols detailed in the monographs
outlined in the USP (USP 24)23 and measuring the API
released using our HPLC method outlined above. The USP
dissolution tolerance rules stipulate that not less than 80%
amoxicillin should dissolve in the media (water) in 60 minutes
(i.e., 0.22 mg/mL for a 250 mg dose and 0.45 mg/mL for a 500 mg
dose), and not less than 70% of each component of sulfameth-
oxazole /trimethoprim should dissolve in the media (0.1 N HCl)
in 60 minutes (i.e., 0.06 mg/mL for a 400/80 mg dose, and
0.12 mg/mL for a 800/160 mg dose).
Sensitivity and specificity calculations. Although the sam-
ple size in this pilot study is small, we have nevertheless ana-
lyzed 27 brands of antibiotics manufactured in 6 countries
(China, Ghana, India, Ireland, Nigeria, and United Kingdom)
and purchased in three countries using MiniLabÒ as a screen-
ing tool and HPLC as the gold standard test. The MiniLabÒ
tests results were compared with the HPLC content analysis
results to assess the sensitivity and specificity of the tests to
detect non-adherent samples. 95% confidence intervals were
calculated using exact binomial distribution.
RESULTS
The sample information and analyses results for each sam-
ple of antibiotic are shown in Tables 1 and 2.
Visual inspection. Majority of the brands of antibiotics
analyzed in this study were labeled as having been produced
as generics in China, Ghana, India, Ireland, and Nigeria. We
were not successful in obtaining the original packets of
generics from manufacturers to help us to compare and dis-
tinguish any differences.
GPHF MiniLabÒ drug quality screening. Results of the
MiniLabÒ tests are classified as pass in the colorimetric test if
the drugs produce the expected color. Similarly for a drug to
be classified as pass using the TLC test, the spot of the
sample should migrate at the same rate as that for the “work-
ing standard solution 80%” of the API, which represents the
lowest acceptable limit.17 All 20 samples of amoxicillin pro-
duced the dark red-brown solution as per the MiniLabÒ
manual for each of these drugs and were classified as pass
whereas two samples, purchased in Ghana, failed the TLC
test (Table 1). A further set of tablets (two per packet) were
90 FADEYI AND OTHERS
Figure 3. High-performance liquid chromatography (HPLC) chromatogram of amoxicillin and co-trimoxazole.
tested from the failed samples to make sure that this was
not a technician error and the samples again failed in the
test. All 15 samples of co-trimoxazole produced a brown
solution hence passing the colorimetric test, and two samples,
one from Ghana and one from Nigeria, failed the TLC test
(Table 2).
HPLC content analysis and dissolution testing. Content
analysis. All the capsules of amoxicillin, except one purchased
in Nigeria, were compliant in the content analysis test. One
co-trimoxazole tablet (obtained in the United Kingdom) was
compliant with the content analysis test, while 14 samples
purchased in Ghana and Nigeria were not. The latter con-
tained between 63% and 90% sulfamethoxazole and 38%
and 88% trimethoprim.
Dissolution testing. All samples of amoxicillin released the
expected amount of API within time and met the USP toler-
ance limits. Of the 15 co-trimoxazole purchased, 6 out of 15
(40.0%) samples (two from Ghana and four from Nigeria)
met USP tolerance limits but 9 out of 15 (60%; three from
Ghana and six from Nigeria) did not.
Sensitivity and specificity calculations. Performance of
MiniLabÒ tests to detect samples noncompliant with HPLC
content analysis are reported in Table 3. Although numbers
are very small, none of the MiniLabÒ tests indicate that these
tests will not be successful at detecting samples that failed the
HPLC content analysis, for either amoxicillin or co-trimoxazole.
However, the MiniLabÒ does demonstrate a low sensitivity
(14%) for co-trimoxazole.
DISCUSSION
Sulfonamides and b-lactam antibiotics have saved countless
lives since their discovery in the 1930s. However, there has
since been a disengagement of most pharmaceutical compa-
nies from antibiotic research as a result of economic and
regulatory challenges. The number of multinational pharma-
ceutical companies actively engaged in antibiotic research
has fallen from 18 in 1990 to just 4 in 2011—AstraZeneca,
Novartis, GlaxoSmithKline (GSK), and Sanofi-Aventis,24 with
countless numbers of generic antibiotics being manufac-
tured globally.
Unremitting treatment using antibiotics is known to select
bacterial strains with physiologically or genetically enhanced
abilities to withstand high concentrations of antibiotics.26 Mis-
use of antibiotics through unnecessary overprescribing and
suboptimal dosing engenders the development of resistance.
Of greater alarm for public health globally is the emergence
of “superbugs” that are extremely resistant to the majority of
antibiotics.27 The threat of superbugs added to the disengage-
ment of pharmaceutical companies makes the maintenance of
good quality antibiotics of paramount importance.26,28 Drug
quality monitoring requires effective tools and regulatory sys-
tems to ensure all available drugs reaching the patients are
quality assured. A systematic literature review found there to
be a prevalence of poor quality antimicrobial medicines, with
the majority of studies focusing on antimalarial drugs in sub-
Saharan Africa and Asia reporting that up to 30% purchased
predominately using convenience sampling in 21 sub-Saharan
countries, failed the chemical content analysis.29
The GPHF MiniLabÒ colorimetric test produced the
expected change in color for all the samples of antibiotics
tested. Although, the TLC test will pass all samples that con-
tain greater than 80% API, it did not result in the expected
migration of spots for two samples of amoxicillin bought
in Ghana (one was stated to be manufactured in United
Kingdom and the other in Ghana) even after retesting using
two other tablets in the packet. Furthermore, two samples of
co-trimoxazole bought and stated to be manufactured in
Ghana and Nigeria, respectively, also failed the TLC test.
 QUALITY OF ANTIBIOTICS 91

Table 1
Sample information and analyses results for amoxicillin
HPLC
Drug (total no Brand; manufacturer; Expiry date Strength MiniLabÒ MiniLabÒ content analysis Dissolution test
of samples) country of manufacture Country of purchase (month-year) (mg) CT TLC test adherence compliance

Co-Trimoxazol; Letap Ghana Apr-12 250 Pass Pass Yes Yes

Pharmaceuticals
Ltd; Ghana
Amoxicillin; Ayrton Ghana Oct-13 250 Pass Pass Yes Yes
Drug Mfg; Ghana
Amoxicillin 250 mg; Ghana Jan-14 250 Pass Pass Yes Yes
GR Industries
Ltd; Ghana
Amoxylex; Luex Ghana Jun-12 250 Pass Pass Yes Yes
Healthcare;
United Kingdom
Permoxyl 500; Ernest Ghana Jan-14 500 Pass Fail Yes Yes
Chemicals; Ghana
Promox capsules 500 mg; Ghana Jan-13 500 Pass Fail Yes Yes
Medreich PLC;
United Kingdom
Amoram 500 mg capsules; Ghana Oct-12 500 Pass Pass Yes Yes
LPC Medical (UK) Ltd;
United Kingdom
Amoxicillin 500 mg; Ghana Apr-12 500 Pass Pass Yes Yes
GR Industries; Ghana
Floximox; Evans Medical; Nigeria Not stated 250 Pass Pass No Yes
Nigeria
Amoxicillin Amoxil; Beecham/Medreich; Nigeria Apr-13 250 Pass Pass Yes Yes
capsules (N = 20) India
ReichamoxÒ; Medreich; India Nigeria Sep-11 250 Pass Pass Yes Yes
Moxitin-500 Amoxicillin Nigeria Oct-13 500 Pass Pass Yes Yes
capsules B.P.; Clarion
Medical; China
Amoxicillin 250 mg United Kingdom Aug-12 250 Pass Pass Yes Yes
capsules BP;
Milpharm Ltd;
United Kingdom
Amoxicillin capsules United Kingdom Nov-11 250 Pass Pass yes Yes
BP; Actavis;
United Kingdom
AmoxilÒ capsules 250 mg; United Kingdom Jan-14 250 Pass Pass Yes Yes
GSK; United Kingdom
Amoxicillin 250 mg United Kingdom Nov-12 250 Pass Pass Yes Yes
capsules; Medreich
PLC; England
Ranbaxy Amoxicillin; United Kingdom Jan-12 250 Pass Pass Yes Yes
Ranbaxy; Ireland
Amoxicillin 500 mg United Kingdom Feb-15 500 Pass Pass Yes Yes
capsules; Athlone
Laboratories; Ireland
Amoxicillin 500 mg capsules; United Kingdom Nov-13 500 Pass Pass Yes Yes
Accord Healthcare Limited;
United Kingdom
Amoxicillin capsules; United Kingdom Jul-11 500 Pass Pass Yes Yes
Amoxicillin Trihydrate;
Morningside Pharmaceuticals;
United Kingdom
Total passed (%) 20/20 (100.0) 18/20 (90.0)
Total failed (%) 2/20 (10.0)
Total compliant with USP tolerance limits (%) 19/20 (95.0) 20/20 (100.0)
Total noncompliant with USP tolerance limits (%) 1/20 (5.0)
CT = colorimetric test; GSK = GlaxoSmithKline group of companies; HPLC = high-performance liquid chromatography; TLC = thin-layer chromatography; USP = U.S. Pharmacopeia.
The USP content limits state that 90–120% of the stated dose of amoxicillin must be measured for the tablets to be classified as compliant.

Co-trimoxazole is the recommended drug by the WHO for
use as a prophylactic therapy to decrease the burden of bacte-
rial infections for people living with HIV and tuberculosis.30
Indeed, in Nigeria it is indicated for the prevention of several
secondary bacterial and parasitic infections in HIV-infected
individuals.31 It is therefore worrying that in our study, 9 out
of the 15 tablets of co-trimoxazole subjected to dissolution
testing did not meet the USP tolerance limits. These subthera-
peutic tablets were all bought in Ghana and Nigeria, stating
that they were manufactured in those countries, except for one
that states it was manufactured in India. These tablets did not
contain an acceptable amount of the stated API (93–107%)
92 FADEYI AND OTHERS

Table 2
Sample information and analyses results for co-trimoxazole
Drug (total no Brand; manufacturer; Expiry date Strength MiniLabÒ MiniLabÒ HPLC content Dissolution test
of samples) country of manufacture Country of purchase (month-year) (mg) CT TLC test analysis adherence compliance

Isokin; Kinapharma Ghana May-14 400/80 Pass Pass No Yes

Limited; Ghana
Deptrin 480; Ghana Jul-13 400/80 Pass Fail No No
Dandams; Ghana
Co-Trimaxole; Letap Ghana Dec-12 400/80 Pass Pass No No
Pharmaceuticals; Ghana
Co-Tri; Ayrton Ghana Nov-13 400/80 Pass Pass No Yes
Drugs; Ghana
Sulfatrim Forte; Shalina Ghana Aug-12 800/160 Pass Pass No No
Laboratories Pvt Ltd; India
PrimpexÒ; SKG Nigeria Mar-16 400/80 Pass Pass No Yes
Pharmaceuticals; Nigeria
Co-trimoxazole Jutrim; Juhel Nigeria Nigeria Jan-14 400/80 Pass Pass No No
tablets (N = 15) Ltd; Nigeria
Jutrim; Juhel Nigeria Nigeria Feb-14 400/80 Pass Pass No No
Ltd; Nigeria
EmtrimÒ; Emzor Nigeria Jun-14 400/80 Pass Pass No Yes
Pharmaceutical Industries
Ltd; Nigeria
Loxaprim; May and Baker Nigeria Aug-14 400/80 Pass Fail No No
Nigeria PLC; Nigeria
Loxaprim; May and Baker Nigeria Oct-15 400/80 Pass Pass No Yes
Nigeria PLC; Nigeria
Bactrim ForteÒ; Swiss Pharma Nigeria Oct-15 800/160 Pass Pass No No
Ltd; Nigeria
Bactrim ForteÒ; Swiss Pharma Nigeria Oct-15 800/160 Pass Pass No No
Ltd; Nigeria
Bactrim ForteÒ; Swiss Pharma Nigeria Aug-13 800/160 Pass Pass No No
Ltd; Nigeria
Co-Trimoxazole 80 mg/400 mg United Kingdom Jul-13 400/80 Pass Pass Yes Yes
Tablets; Glaxo Wellcome
GmbH and Co;
United Kingdom
Total passed (%) 15/15 (100.0) 13/15 (86.7)
Total failed (%) 2/15 (13.3)
Total compliant with USP tolerance limits (%) 1/15 (6.67) 6/15 (40.0)
Total noncompliant with USP tolerance limits (%) 14/15 (93.3) 9/15 (60.0)
CT = colorimetric test; GSK = GlaxoSmithKline group of companies; HPLC = high-performance liquid chromatography; TLC = thin-layer chromatography; USP = U.S. Pharmacopeia.
The USP content limits state that 93–107% of the stated dose of components of co-trimoxazole must be measured for the tablets to be classified as compliant.

when tested for content with amounts of sulfamethaxozale ranging MiniLabÒ was more useful for testing amoxicillin but dispar-
between 63% and 90% and trimethoprim ranging between ity was found between the results obtained when assessing the
38% and 88%. quality of co-trimoxazole using the MiniLabÒ TLC test and
The quality of amoxicillin assessed using both the MiniLabÒ the HPLC content analysis. The TLC method detected only
and the HPLC analysis for content produced some anomalies. two noncompliant samples out of the total 15, whereas HPLC
Two samples from Ghana failed the MiniLabÒ TLC test but content analysis determined 14 samples of co-trimoxazole to
were found to be compliant by HPLC content analysis. One be noncompliant. This underestimation of poor quality using
sample from Nigeria passed the MiniLabÒ TLC test but was the TLC test demonstrates the lack of accuracy of the
found to be noncompliant by HPLC content analysis. The MiniLabÒ to detect noncompliant samples of certain drugs
such as co-trimoxazole in this study. This limitation has been
previously reported in a study assessing the quality of anti-
Table 3 malarials in sub-Saharan Africa in which the MiniLabÒ TLC
Sensitivity and specificity of MiniLabÒ tests for detecting drugs method failed to detect noncompliance (as determined by
noncompliant with HPLC content analysis (frequency,
proportion, and 95% exact confidence interval) HPLC) of 59% of 41 samples of artemisinin combination ther-
Antibiotic Test Sensitivity Specificity
apy drugs and sulfadoxine–pyrimethamine.32 The MiniLabÒ
is a suitable screening tool in the absence of MQCLs; how-
Amoxicillin MiniLabÒ CT
0/1 19/19
ever, it has been reported that it can only detect grossly sub-
0% [0.0–97.5] 100% [82.3–100.0]
MiniLabÒ TLC 0/1 17/19 standard or counterfeit drugs, which has been highlighted
0% [0.0–97.5] 89.5% [66.9–98.7] here with co-trimoxazole.33 Indeed specificity and sensitivity
Co-trimoxazole MiniLabÒ CT 0/14 1/1 calculations of our analysis results, even though our sample size
0% [0.0–23.2] 100% [0.0–23.2] was small, support the published findings, as the MiniLabÒ
MiniLabÒ TLC 2/14 1/1
14% [1.8–42.8] 100% [2.5–100.0] demonstrates a low sensitivity for co-trimoxazole tablets when
HPLC = high-performance liquid chromatography; MiniLabÒ CT = colorimetric test;
compared with content analysis with HPLC. All the samples
MiniLabÒ TLC = semi-quantitative thin layer chromatography. passed the colorimetric test and only two failed the TLC test.
 QUALITY OF ANTIBIOTICS
Therefore, the MiniLabÒ cannot be relied upon unequivocally
for drug quality monitoring, and for definitive results precise
analytical methods such as HPLC and dissolution testing need
to be utilized.19 It is worth noting that results provided by the
MiniLabÒ are intrinsically linked to the drug-specific protocol
for testing, and so perhaps this is an aspect that needs to be
assessed by the manufacturer. Studies with larger sample sizes
need to be undertaken with a number of the main classes of
anti-infective drugs to determine the sensitivity and specificity
of the MiniLabÒ.
Notably no falsified samples were identified in this study,
even though the sample size was small, but substandard
co-trimoxazole samples containing less than 93% APIs have
been detected. These may have been produced following poor
manufacturing practices where the facilities have not been cer-
tified to have met “Good manufacturing practice” status, which
may be the case in resource-poor settings.34 The impact of
substandard co-trimoxazole at the patient level may be a longer
recovery time from infection increasing the burden on health
services and the inevitable impact on the productivity of the
individuals and/or carer(s). However, at the population level
substandard co-trimoxazole may engender drug resistance.
Lack of funds and time entailed that samples were pur-
chased using the convenience method with an overt approach.
Convenience sampling is not the method of choice to deter-
mine the prevalence of poor quality drugs in a geographical
region, and overt sampling may lead to responder bias as the
seller is aware of the nature of the study and will provide
samples that are more likely to be of good quality.35
In conclusion, there has been much attention focused on
the quality of antimalarials as well as the quality of antiretro-
viral drugs for HIV and drugs for the treatment of tubercu-
losis in parts of southeast Asia and sub-Saharan Africa.
However, a concerted effort is needed to also determine the
quality of varying brands of antibiotics in various countries.
The sheer volume of antibiotics sold daily and their relatively
low production cost makes them a vulnerable group of drugs
for targeting by counterfeiters, illegitimate internet pharma-
cies, and those drug manufacturers who use poor manufactur-
ing practices.32 The use of screening tools such as the MiniLabÒ
is vital for countries that do not have a MQCL, but our work
has shown that it does not work well for one of the two
antibiotics that we tested and further investigation is war-
ranted with greater sample number and other antibiotics.
This study further endorses the need for developing nations
to invest in capacity building integrating national MQCLs.
Investment must include improving technical capacity so that
drug quality analysis can be conducted using reliable and
accurate methods such as HPLC and dissolution testing to be
a part of an integrated drug quality surveillance system.
Received August 27, 2014. Accepted for publication February 1, 2015.
Published online April 20, 2015.
Acknowledgments: We are grateful to Issac Asante and Mathilda
Tivura of the Kintampo Health Research Centre, for their help in
purchasing the samples of antibiotics in Kintampo, Ghana. We are
also grateful to Elizabeth Louise Allan for her valuable comments on
this manuscript. Baptiste Leurent is thanked for his help with the
statistical analysis.
Financial support: We are grateful to the Gates Malaria Partnership
for providing support for the analytical facility through an award
93
from the Bill and Melinda Gates Foundation to the London School
of Hygiene & Tropical Medicine.
Authors’ addresses: Ifeyinwa Fadeyi, Mirza Lalani, Naiela Mailk,
Albert Van Wyk, and Harparkash Kaur, London School of
Hygiene & Tropical Medicine, London, United Kingdom, E-mails:
ifeyinwa.fadeyi@lshtm.ac.uk, mirza.lalani@lshtm.ac.uk, naiela-begum
.malik@lshtm.ac.uk, albert.vanwyk@gmail.com, and harparkash
.kaur@lshtm.ac.uk.
This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the
original author and source are credited.
REFERENCES
1. Currie CJ, Berni E, Jenkins-Jones S, Poole CD, Ouwens M,
Driessen S, de Voogd H, Butler CC, Morgan CL, 2014. Anti-
biotic treatment failure in four common infections in UK
primary care 1991–2012: longitudinal analysis. BMJ 349: g5493.
2. Gonzalo X, Drobniewski F, 2013. Is there a place for beta-
lactams in the treatment of multidrug-resistant/extensively
drug-resistant tuberculosis? Synergy between meropenem and
amoxicillin/clavulanate. J Antimicrob Chemother 68: 366–369.
3. Wright TI, Baddour LM, Berbari EF, Roenigk RK, Phillips PK,
Jacobs MA, Otley CC, 2008. Antibiotic prophylaxis in derma-
tologic surgery: advisory statement 2008. J Am Acad Dermatol
59: 464 – 473.
4. Wiktor SZ, Sassan-Morokro M, Grant AD, Abouya L, Karon
JM, Maurice C, Djomand G, Ackah A, Domoua K, Kadio
A, Yapi A, Combe P, Tossou O, Roels TH, Lackritz EM,
Coulibaly D, Cock KMD, Coulibaly I-M, Greenberg AE,
1999. Efficacy of trimethoprim-sulphamethoxazole prophy-
laxis to decrease morbidity and mortality in HIV-1-infected
patients with tuberculosis in Abidjan, Côte d’Ivoire: a ran-
domised controlled trial. Lancet 353: 1469–1475.
5. Alahdab Y, Kalayci C, 2014. Helicobacter pylori: management
in 2013. World J Gastroenterol 18: 5302–5307.
6. Nayyar GM, Breman JG, Newton PN, Herrington J, 2012. Poor-
quality antimalarial drugs in southeast Asia and sub-Saharan
Africa. Lancet Infect Dis 12: 488– 496.
7. Tabernero P, Fernandez FM, Green M, Guerin PJ, Newton PN,
2014. Mind the gaps—the epidemiology of poor-quality anti-
malarials in the malarious world—analysis of the WorldWide
Antimalarial Resistance Network database. Malar J 13: 139.
8. World Health Organization, 2011. Spurious/falsely-labelled/
falsified/counterfeit (SFFC) medicines. Available at: http://www
.who.int/medicines/services/counterfeit/faqs/QandAsUpdateJuly11
.pdf. Accessed May 27, 2014.
9. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Taylor TH, 2014.
Trends and seasonal variation in outpatient antibiotic prescrip-
tion rates in the United States, 2006 to 2010. Antimicrob
Agents Chemother 58: 2763–2766.
10. Hadi U, van den Broek P, Kolopaking EP, Zairina N, Gardjito
W, Gyssens IC, Study Group Antimicrobial Resistance in
Indonesia P, Prevention A, 2010. Cross-sectional study of
availability and pharmaceutical quality of antibiotics requested
with or without prescription (over the counter) in Surabaya,
Indonesia. BMC Infect Dis 10: 203.
11. Al-Shami A, Izham M, Abdo-Rabbo A, 2011. Evaluation of the
quality of prescriptions with antibiotics in the government
hospitals of Yemen. J Clin Diagn Res 5: 808– 812.
12. Newton PN, Green MD, Fernandez FM, 2010. Impact of poor-
quality medicines in the ‘developing’ world. Trends Pharmacol
Sci 31: 99–101.
13. Kelesidis T, Kelesidis I, Rafailidis PI, Falagas ME, 2007. Coun-
terfeit or substandard antimicrobial drugs: a review of the
scientific evidence. J Antimicrob Chemother 60: 214 –236.
14. Seear M, Gandhi D, Carr R, Dayal A, Raghavan D, Sharma
N, 2011. The need for better data about counterfeit drugs
in developing countries: a proposed standard research meth-
odology tested in Chennai, India. J Clin Pharm Ther 36:
488– 495.
94 FADEYI AND OTHERS
15. Kyriacos S, Mroueh M, Chahine RP, Khouzam O, 2008. Quality
of amoxicillin formulations in some Arab countries. J Clin
Pharm Ther 33: 375–379.
16. Newton PN, Green MD, Fernandez FM, Day NP, White NJ,
2006. Counterfeit anti-infective drugs. Lancet Infect Dis 6:
602– 613.
17. Global Pharma Health Fund, 2012. GPHF MiniLabÒ. Available
at: www.gphf.org. Accessed May 17, 2014.
18. Available at: http://www.usp.org/global-health-programs/promoting-
quality-medicines-pqmusaid/pqm-news-resource-center/glossary-
pqm-activities#trainingPrograms. Accessed March 3, 2015.
19. Kaur H, Green MD, Hostetler D, Fernandez FM, Newton PN,
2010. Antimalarial drug quality: methods to detect suspect
drugs. Therapy 7: 40–57.
20. 2009. Map of Nigeria. Available at: http://en.18dao.net/Map/
Nigeria. Accessed June 2, 2014.
21. 2009. Map of Ghana. Available at: http://en.18dao.net/Map/
Ghana. Accessed June 2, 2014.
22. Available at: http://epi-info.software.informer.com/3.5/. Accessed
August 25, 2014.
23. The United States Pharmacopeia, 2000. USP 24: The National
Formulary: NF 19: United States Pharmacopeial Convention.
Rockville, MD: United States Pharmacopoeia.
24. Butler MS, Blaskovich MA, Cooper MA, 2013. Antibiotics in the
clinical pipeline in 2013. J Antibiot (Tokyo) 66: 571–591.
25. Antimicrobial resistance: revisiting the “tragedy of the commons”
interview; Professor John Conly on World Health Day 2011.
Available at: http://www.who.int/bulletin/volumes/88/11/10-
031110/en/. Accessed August 21, 2014.
26. Levy SB, 1994. Balancing the drug-resistance equation. Trends
Microbiol 2: 341–342.
27. McKendry RA, 2013. Nanomechanics of superbugs and super-
drugs: new frontiers in nanomedicine. Biochem Soc Trans 40:
603– 608 [Review].
28. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F,
Balakrishnan R, Chaudhary U, Doumith M, Giske CG, Irfan
S, Krishnan P, Kumar AV, Maharjan S, Mushtaq S, Noorie T,
View publication stats
Paterson DL, Pearson A, Perry C, Pike R, Rao B, Ray U,
Sarma JB, Sharma M, Sheridan E, Thirunarayan MA, Turton
J, Upadhyay S, Warner M, Welfare W, Livermore DM,
Woodford N, 2010. Emergence of a new antibiotic resistance
mechanism in India, Pakistan, and the UK: a molecular, bio-
logical, and epidemiological study. Lancet Infect Dis 10:
597–602.
29. Almuzaini T, Choonara I, Sammons H, 2013. Substandard and
counterfeit medicines: a systematic review of the literature.
BMJ Open 3: e002923.
30. World Health Organization, 2011. Adapting WHO Normative
HIV Guidelines for National Programmes: Essential Principles
and Processes. Available at: http://whqlibdoc.who.int/publications/
2011/9789241501828_eng.pdf. Accessed July 31, 2014.
31. Federal Ministry of Health Nigeria, 2010. National Guidelines for
HIV and AIDS Treatment and Care in Adolescents and Adults.
Available at: http://www.who.int/hiv/pub/guidelines/nigeria_art
.pdf. Accessed July 31, 2014.
32. World Health Organization, 2011. Survey of the Quality of
Selected Antimalarial Medicines Circulating in Six Countries
of Sub-Saharan Africa. Available at: http://www.who.int/
medicines/publications/WHO_QAMSA_report.pdf. Accessed
June 16, 2014.
33. Risha PG, Msuya Z, Clark M, Johnson K, Ndomondo-Sigonda M,
Layloff T, 2008. The use of MiniLabsÒ to improve the testing
capacity of regulatory authorities in resource limited settings:
Tanzanian experience. Health Policy 87: 217–222.
34. Caudron JM, Ford N, Henkens M, Mace C, Kiddle-Monroe R,
Pinel J, 2008. Substandard medicines in resource-poor settings:
a problem that can no longer be ignored. Trop Med Int Health
13: 1062–1072.
35. Newton PN, Lee SJ, Goodman C, Fernández FM, Yeung S,
Phanouvong S, Kaur H, Amin AA, Whitty CJ, Kokwaro GO,
Lindegårdh N, Lukulay P, White LJ, Day NP, Green MD,
White NJ, 2009. Guidelines for field surveys of the quality of
medicines: a proposal. PLoS Med 6: e52.